On track to emerge from bankruptcy next month, Rural/Metro Medical Services finds itself in another imbroglio — this one involving a turf war with suburban ambulance services on the county's east side.

"It's just silly, what they're doing," said Thomas Bonfiglio, division general manager for Rural/Metro. "It doesn't make any sense, and it's bad for patients."

The basics are these: Rural/Metro took over coverage of East Rochester in June and claims surrounding ambulance services started bypassing it for mutual aid or backup assistance. Rural/Metro effectively told the surrounding towns that their help no longer was needed, either.

So now, ambulance services from Victor-Farmington and Honeoye Falls-Mendon are assisting the towns around East Rochester, while Rural/Metro sends its own backup units from the city.

All claim that patient care has not suffered, thanks to the wealth of resources available. But the result has been outside ambulances, at times, crisscrossing past other units already stationed in the communities.

Rural/Metro has refused to sign an updated mutual aid plan — and effectively quashed its implementation — by demanding that its ambulances be the first called for mutual aid. In short, Rural/Metro upset a decades-long mutual reliance among the eastern suburbs' volunteer companies but claims it is justified and has both the resources and state authority to do so.

The counter argument to Rural/Metro's claim of 24-7 availability inevitably gets back to its city performance. The Arizona-based company paid $30,750 in penalties to the city of Rochester last month for late arrivals to 911 calls, according to reports the Democrat and Chronicle obtained through an open records request. Rural/Metro has an exclusive contract in the city with strict performance measures, resulting in $301,650 in fines so far this year.

The city contract is one of Rural/Metro's 10 largest nationally in terms of call volume but most expensive in western New York. The fines for late arrivals, which vary in severity by type of call, are in addition to an annual $300,000 franchise fee. By comparison, the company pays nothing to do business in Syracuse and a $350,000 franchise fee in Buffalo but no performance penalties.

Despite the fines, both city and Rural/Metro officials say the service is meeting or exceeding standards, and there has been no fall-off since the company declared Chapter 11 bankruptcy earlier this year or took on East Rochester coverage.

"There are more things that qualify for fines, and the fines are higher," Rochester Fire Chief Salvatore "Sam" Mitrano III said, referring to penalties imposed under a renewed city contract effective in March. That said: "They are running the same now as they were six months ago."

Rural/Metro has been Rochester's preferred service provider for more than two decades and, when battling to retain the agreement in 2008, estimated the contract's value at $15 million to $20 million.

In East Rochester, town/village officials sought proposals and invited Rural/Metro to take over what was the state's oldest continuously active, independent, volunteer ambulance corps. The taxpayer-subsidized service, begun in 1938, was struggling to attract volunteers and, at one point, had a dismal local response rate of 56 percent, according to a state audit. Financial shortfalls were blamed on low call volumes in the village of 6,600.

Line in the sand

Skirmishes among ambulance providers are commonplace across Monroe County and the state. But officials say the situation on the east side of the county — also involving a private paramedic service operating out of the Pittsford Ambulance station — is particularly complex. It will serve as a test site next year for putting GPS locators in ambulances, allowing 911 dispatchers to see which ambulance is closest to a call.

Rural/Metro has GPS on all of its ambulances but it is not currently incorporated into the 911 system.

Getting GPS units in the ambulances might go a long way toward resolving the turf battles, as agencies otherwise choose who takes the calls they cannot. In a decades-long practice, each fills out what's known as a "run card" designating their preferred backup. Once Rural/Metro took over in East Rochester, several agencies edited their cards to omit or demote East Rochester, said Stephen Cusenz, deputy director of the 911 center.

For neighboring Pittsford, East Rochester now ranks no higher than third (unless Rural/Metro has contracted with a nursing home), where they used to be second.

"If you are the guy having a heart attack, I don't think you care what the ambulance looks like as long as it gets there," Cusenz said, but when it comes to East Rochester: "They are no longer being called."

While all say the goal is patient care, there is a business aspect to this dispute.

Years ago, in an effort to cut down on competition among providers, the state certified companies to operate within certain territories. Only Rural/Metro and Monroe Ambulance have jurisdiction across the county.

Under state policy, adopted in 2006, the first mutual aid call must go to the service with operating authority. That would mean either Rural/Metro or Monroe Ambulance would always be the first called for mutual aid. If they were not available, the call then would go to the closest unit available. That policy is one of many, which the towns argue leaves matters open to interpretation. And there had been little or no enforcement until Rural/Metro began pressing the matter.

Pittsford officials suspect Rural/Metro is just looking for ways to increase profits after committing itself to financially depressed markets. Then again, Pittsford had received most of the mutual aid calls into East Rochester before Rural/Metro arrived. Both say the volume of calls is minimal, however. And yet the turf battle persists.

In one instance, Bonfiglio claimed, a Honeoye Falls-Mendon ambulance was summoned to a Pittsford address within sight of Rural/Metro's East Rochester station, which had an ambulance in quarters.

Not knowing the circumstances, Forsyth said, the example highlights a key point of the dispute. Rural/Metro, citing the state policy, would always be dispatched for mutual aid. But if the call involved, for example, a broken foot, it would make more sense to send one of the town ambulances (which do not have a paramedic on board) and leave the paramedic-staffed Rural/Metro unit available for life-saving calls. That argument also is effective in limiting the times Rural/Metro gets called.

"I'm not aware of any circumstances in which patient care has suffered," said Jeremy Cushman, county/regional EMS director — who also is medical director for Perinton Ambulance. "That said, we clearly can do better."

He added: "Our current practices are at odds between what is legal and what is in the patient's best interest."

Take the mutual aid plan.

The revised plan had the various services positioning units throughout the day based on where the calls were, and knowing what areas typically have higher call volumes. The goal was to gather enough data to prove its case to the state.

"It was working, and patients were getting better care," Forsyth said, claiming Rural/Metro backed out and pressured the county and 911. "Unfortunately, we had to stop that ... (and) we were not able to run statistics for a long enough period of time."

Bonfiglio sees matters differently, as inefficient, uneccessary: "We are sitting right here in the middle. ... Maybe they view us as a threat. Their town can make the same determination" as East Rochester did and dump the taxpayer-subsidized ambulance service. Pittsford's subsidy is low, however, at just over $100,000. Compare that with $667,000 in Henrietta.

Paying the bills

Rural/Metro has more ambulances locally than ever before, officials said, with four new units being added to bring the total fleet to 46. (Pittsford currently has four, and will add a fifth in the spring.) At any given time there are 25 to 30 Rural/Metro units on the road. The addition of two critical care trucks brings the fleet of support vehicles to six.

When Rural/Metro emerges from bankruptcy in December, local officials expect little or no effect locally from the reorganization.

In court filings last month, Rural/Metro revealed that the national company was facing a budget shortfall of $20 million or more caused by outdated and erroneous revenue calculations. The company noted expenses for franchise fees and performance penalties, but it was a miscalculation of its communities' payor mix — those with and without insurance, or on Medicare and Medicaid — and problems with billing that got the company finances so out of whack.

Rural/Metro writes off close to 60 percent of its billings as noncollectable in Rochester, Bonfiglio said. In Pittsford, less than 10 percent of billings go uncollected. Collection rates are better in the suburbs, and nonemergency transports between medical facilities pay best. But Rural/Metro does nearly all of its business on 911 responses.

"We're better than most urban areas," Cushman said. "Believe it or not, even a 30 percent collection rate is pretty good."

The city contract states that for priority calls, Rural/Metro must be on scene within 8 minutes, 59 seconds "for each incident, and at 90 percent reliability for all assignments, in each zone." The statement is repeated for other call types and time limits. The city reads that as saying that Rural/Metro must meet the 90 percent mark by zone but not call type, and expects Rural/Metro would be more challenged on lower priority calls that are far fewer in number, thus easily skewing any percentage.

"When you look into the call details ... typically you will see a minute late, 30 seconds late — still well within a reasonable response time (but it) might be outside the strict standards," Bonfiglio said.

Rural/Metro hits the 90 percent mark by call type when it checks the numbers, he said, but the company does not do such checks regularly. He adds: "There has not been a single complaint on response times in a very long time."

Rural/Metro's on-time response rate has remained relatively steady overall. Last month's penalties resulted from 371 instances of late arrivals out of more than 5,000 calls, which meets the city requirement for an on-time response rate of 90 percent or better.

The city further sought to improve times with a number of changes in the most recent contract, which took effect in spring 2012. Since then, fine revenue has tripled, with money going into the city's general fund. Exceptions are made, such as if a major snowstorm makes travel treacherous. Bonfiglio said the company budgeted accordingly but has not made cuts to accommodate the penalties.

Monroe Ambulance, which has competed with Rural/Metro for the city contract, did not return a phone call seeking comment for this story.

Solutions

A February study of Monroe County's Emergency Medical Services by Fitch & Associates LLC was highly critical of how county ambulance service is provided. It offered the following options for moving forward:

Keep the present system: "Until the communities become aware that the existing 'system' does not perform to nationally accepted standards, there is little incentive to abandon the status quo," according to the report.

More centralized authority: Give the county EMS office more authority to define countywide policies on a consistent basis. Empower the office to promote performance and gather specific performance data. Part of this option includes installing a GPS tracking system similar to the one that will be tested next year.

Change the model: Consider Monroe County outside Rochester as a single service district. Retain all existing ambulance agencies and have them contribute units to 911 on a per shift basis and from optimum locations.

Change the model II: Consider all of Monroe County outside of Rochester as a single district and put its emergency services out to a competitive bidding process.